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Musculoskeletal Problems

ARC: Learning Guide for GPs and GP Registrars on Musculoskeletal Problems

Introduction

There are three sections to this learning guide:

Core clinical topics
Principal drug groups used
Other health care workers involved in the care of musculoskeletal problems

This is a learning guide, not a textbook. It is intended that the Registrar and their Trainer should use this as a guide to the areas that the registrar should be familiar with at the end of their registrar year. No attempt has been made to rate the nature and quality of the evidence base that informs decision-making in these areas. The registrar is urged to use currently available material to form his or her own judgement on this. The topics covered in the 'Rheumatic Disease: In Practice' series published by the Arthritis Research Campaign are based on this learning guide.

i. Core Clinical Topics

The Registrar should have a working knowledge of the core clinical topics listed below. They should each be considered in the general framework described overleaf. Being able to elicit an appropriate history, perform an appropriate examination and having an appropriate knowledge of epidemiology is fundamental to all of these topics. Some examples of key points pertinent to the core clinical topics are listed in Appendix One.

Acute back/neck pain
Chronic back/neck pain
Shoulder pain
Knee pain
Soft tissue disorders
Osteoarthritis
Osteoporosis
Somatisation/fibromyalgia and allied syndromes
Pain management
Acute arthropathies
Chronic inflammatory arthropathies
Polymyalgia rheumatica and allied conditions
Awareness of rare diseases
Chronic disability

General framework for considering core clinical topics

1. Clinical Assessment

Red flags
Knowledge	Knowledge of conditions that require urgent or emergency referral
Skills	Making appropriate urgent or emergency referrals
Symptoms and signs
Knowledge	Common conditions Important uncommon conditions Differential diagnosis
Skills	History-taking Appropriate musculoskeletal examination
Investigations
Knowledge	Use of blood and radiological investigations
Skills	Interpretation of blood and radiological investigations

2. Functional assessment/patient impact

Knowledge	Awareness of the impact of their condition on their lives
Skills	Knowing what is available to help and how to access it

3. Epidemiology

Knowledge	Simple epidemiology (e.g. approximate incidence/prevalence, major risk factors) An appreciation of the resource implications of managing musculoskeletal disorders
Skills	Integrating epidemiology into the diagnostic process Being able to distinguish between individuals with minor self-limiting symptoms and those at high risk of developing musculoskeletal disability

4. Attitude

Knowledge	Using terms which patients understand that are medically correct and avoid unnecessary medicalisation Understanding of cultural and religious differences
Skills	Being able to approach patients without discriminating on grounds of age, size, ethnic group, or understanding Using available research evidence Being able to work with other orthodox, and heterodox, professions. Avoiding unnecessary prescribing Being positive about musculoskeletal problems

5. Team working

Knowledge	Complementary skills of physical therapists/ alternative practitioners and secondary care
Skills	Team working and referral strategies

6. Prevention

Knowledge	Modifiable risk factors Occupational risk
Skills	Identifying high-risk groups Targeting advice and intervention

7. Patient empowerment

Knowledge	Sourcing relevant educational material Awareness of support groups
Skills	Facilitating the development of self-help strategies

8. Principles of rational management of patient's condition

Knowledge	Drug treatment Non-drug treatment Injection techniques Complementary therapies Manipulation
Skills	Communication/advice Use of bio-psychosocial model to de-medicalise common disorders Team working Appropriate use of oral and topical medications Appropriate referral to secondary care Appropriate referral to professions allied to medicine Injection techniques (desirable but not essential)

9. Management of impact of condition on the individual and society

Knowledge	Benefit entitlement Occupational health Aids and appliances Orthotics Physical, social and psychological impact of disability Genetic implications Medico-legal Educational needs
Skills	Communication skills Using appropriate terminology Setting realistic goals Team working Having a sensitive approach to sexual and other delicate issues

ii. Principal drug groups used

The registrar should be familiar with the appropriate use of drugs from the following groups in the management of musculoskeletal problems in primary care.

NSAIDs
Steroids
Non-opiate analgesics
Compound analgesics
Local injections
Osteoporosis treatment and prevention
(bisphosphonates, calcium and vitamin D, HRT, selective oestrogen receptor modulators - SERMs)
Disease-modifying anti-rheumatic drugs (DMARDs)
Anti-depressants

iii. Other health care workers

The registrar should be familiar with the roles and training of other health care workers to whom they may refer their patients, or who their patients might consult without referral. Important issues when considering other therapists include:

Training

Registration

Medico-legal considerations

Types of patients/clients who may benefit from consulting them

Therapeutic/other approach

Evidence for effectiveness of approach

They should be familiar with the input that the following professional groups/organisations can have to the care of their patients with musculoskeletal problems

	Charities
	Chiropodists
	Chiropractors
	Community nurses
	Complementary practitioners
	Occupational therapists
	Osteopaths
	Physiotherapists
	Rheumatologists
	Rheumatology specialist nurses
	Self-help organisations
	Young disabled units

Appendix One: Examples of key points pertinent to the core clinical topics

1. Acute back/neck pain

Clinical assessment

Diagnostic triage
Rational use of imaging

Principles of rational management

Early reactivation
Team approach

2. Chronic back/neck pain

	Clinical assessment Bio-psychosocial yellow flags
	Epidemiology Economic cost Sickness certification
	Functional assessment/patient impact Sick role Illness behaviour
	Attitude Coping with difficult-to-help patients
	Principles of rational management Pain management De-medicalisation Team working Awareness of psychological dysfunction Drug vs. non-drug management

3. Shoulder pain

	Clinical assessment Functional anatomy of the shoulder Examination of shoulder joint
	Principles of rational management Familiarity with relative efficacy of drug and non-drug therapies Familiarity with the role of injections for shoulder pain.

4. Knee pain

	Clinical assessment Functional anatomy of the knee Examination of knee joint Appropriate investigations
	Epidemiology Problems affecting specific age groups
	Principles of rational management NSAIDs vs. simple analgesia Team approach When to refer

5. Soft tissue disorders

	Clinical assessment Familiarity with the following syndromes Medial and lateral epicondylitis Carpal tunnel De Quervain's tenosynovitis Trigger finger Over-use syndromes Trochanteric Bursitis Plantar fasciitis Olecranon bursitis
	Principles of rational management Occupational factors Non-drug management Appropriate medication Understanding the role of local injections

6. Osteoarthritis

	Clinical assessment Appropriate use of investigations Appropriate use and interpretation of radiology reports
	Epidemiology Generalised osteoarthritis Single joint osteoarthritis (hip, knee, first CMP joint)
	Functional impact/patient impact Functional assessment for activities of daily living Illness behaviour and sickness certification
	Principles of rational management Self-help skills and patient education Drugs - stepped approach Secondary prevention Reassurance

7. Osteoporosis

	Clinical assessment Interpreting measures of bone density
	Prevention Identifying patients at high risk of osteoporosis Understanding of the consequences of osteoporosis
	Principles of rational management Prevention Drug treatment of established disease Non-drug treatment of established disease Chronic disease management skills

8. Somatisation/fibromyalgia and allied syndromes

	Clinical assessment Making a clinical diagnosis Cautious use of investigations
	Attitude Positive enabling Bio-psychosocial skills
	Principles of rational management De-medicalisation Avoidance of unnecessary medication Use of anti-depressants Rehabilitation Psychological approaches

9. Pain management

	Clinical assessment History-taking
	Functional assessment/patient impact Awareness of the impact of condition on their lives
	Epidemiology Characteristics of individuals at risk of developing chronic pain syndromes.
	Attitude Coping with difficult-to-help patients
	Team working Appropriate use of the complementary skills of physical therapists/alternative practitioners, psychologists and secondary care
	Prevention Identifying high-risk groups Appropriate advice
	Patient empowerment Sourcing appropriate educational material Facilitating the development of self-help strategies Principles of rational management of patient's condition Knowing what is available to help Complementary therapies Appropriate use of oral and topical medications Communication/advice De-medicalisation Team working Awareness of psychological dysfunction
	Management of impact of condition on the individual and society Role functioning Appropriate terminology Setting appropriate goals Communication skills Awareness of potential problems

10. Acute arthropathies

	Clinical assessment Knowledge of conditions that require urgent or emergency referral Common conditions Important uncommon conditions Appropriate radiology and blood tests Interpretation of investigations
	Epidemiological statistics
	Principles of rational management of patient's condition Appropriate use of medication Knowledge of when injection techniques are appropriate

11. Chronic inflammatory arthropathies

	Functional assessment Awareness of the impact of their condition on their lives
	Team working Appropriate team working within primary care team and across primary/secondary care interface. Appropriate use of complementary skills of physical & occupational therapists
	Principals of rational management of patient's condition Drug treatment Awareness of psychological dysfunction and co-morbid depression
	Management of impact of condition on the individual and society Benefit entitlements Occupational health Aids and appliances Genetic implications Medico-legal implications Sensitive approach to sexual issues

12. Polymyalgia rheumatica and related syndromes

	Clinical assessment Recognition of clinical presentation Urgency Awareness of overlapping conditions Familiarity with the use and interpretation of blood tests for acute phase proteins (ESR, CRP, PV)
	Principles of rational management Appropriate use of steroids

13. Awareness of rare diseases

	Clinical assessment Appropriate use and interpretation of investigations Appropriate referrals
	Epidemiology Integrating epidemiology into the diagnostic process

14. Chronic musculoskeletal disability

	Skills Being able to involve other disciplines and voluntary groups.
	Attitude Being able to cope with the long-term management of chronically disabled patients

Appendix Two: Development of this curriculum

This curriculum was developed by a multi-disciplinary group representing the Arthritis Research Campaign, Primary Care Rheumatology Society and Royal College of General Practitioners. A weekend meeting, funded by an educational grant from Boeringer-Ingelheim was held in January 1999 to develop the structure and general content of this curriculum. The content was subsequently refined in a two-stage postal consultation process.

Members of development group

Brown P, Swansea; Burn L, Richmond, Surrey; Campbell A, Sheffield; Davenport G, Nantwich; Dickson J, Northallerton; Dornan C, Manchester; Doyle C, Sandbach; Edwards J, Stone; Glennon P, Stafford; Hassell A, Haywood Hospital; Hay E, Haywood Hospital; Hill S, North Devon; Hillier A, Northants; Hosie G, Glasgow; Hughes J, Manchester; Longworth S, Leicester; Nanavati B, Manchester; Ormston B, York District Hospital; Rickets M, Queen Mary & Westfield College; Underwood M, Queen Mary & Westfield College; Vaghmaria A, Stoke-on-Trent; Wright S, Manchester.

Published January 2000.

Source: Arthritis Research Campaign Learning guide for GP Registrars on musculoskeletal problems

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